Stem Cells & Infusions Intake Form – Holina Healing Centre – Wellness Resort in Khao Yai, Thailand

Your Journey to Advanced Health at Holina Healing

In order for us to configure the best possible treatment plan for you, please complete this form as honestly as you feel comfortable.

Stem Cells & Infusion Treatments Self Assessment

Personal Information

First name

Last name

Date of birth

Age

Gender

ID / Passport Number

Phone Number

Physical Information

Current body weight (in KG)

Height (in CM)

Usual / Previous Weight (in KG)

Blood type

Rh Factor

Blood pressure (if known)

Do you have any blood born viruses?

Please specify

Reason for Treatment (Stem Cells)

What is the main reason for your referral for stem cell treatment?

When did your symptoms first begin?

What treatments have you tried so far?

Please specify:

Reason for Treatment (NAD+ & Vitamin Infusions)

What is the main reason for your referral for NAD+ & Vitamin Infusions?

When did your symptoms first begin?

What treatments have you tried so far?

Please specify:

Have you been diagnosed with any of the following conditions?

Diabetes

High blood pressure

Heart disease

Kidney disease

Liver disease

Cancer

Autoimmune disease

Other

Please specify:

Have you had any surgeries in the past?

Please specify:

Have you received chemotherapy or radiation therapy?

When did you last receive chemotherapy or radiation therapy?

Medications

Are you currently taking regular medications?

Please list medication names and dosages:

Allergies

Do you have any allergies to medications or foods?

Please specify:

Lifestyle

Do you smoke?

Do you drink alcohol?

Do you use prescribed medication?

Please specify

Do you use non prescribed medications including illegal narcotics?

Previous Stem Cell Treatments

Have you had a stem cell transplant before?

Which year did you have a stem cell transplant before?

Additional Details

Any additional information the medical team should know:

Who referred you?

Please specify:

Patient Declaration

Full name

Information Declaration

I confirm that the information provided above is true and complete.

Stem Cells & Infusion Intake Form

Your Journey to Advanced Health at Holina Healing

Stem Cells & Infusion Treatments Self Assessment

Personal Information

Physical Information

Reason for Treatment (Stem Cells)

Reason for Treatment (NAD+ & Vitamin Infusions)

Medications

Allergies

Lifestyle

Previous Stem Cell Treatments

Additional Details

Patient Declaration

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